Post-Implementation
Getting to ICD-10 is only the tip of
the iceberg; the real challenge is
ensuring the ability to evolve along
with it.
Agenda for Today
ICD-10 Coding Refresher
Documentation for Specificity
Post ICD-10 Implementation-Who, What, Why
and When?
Why Did We Need a New Coding System?
Exactness
Identify diagnoses and procedures precisely
Reimbursement
Would enhance accurate payment for services rendered
Flexibility
To quickly incorporate emerging diagnoses and procedures
Quality
Would facilitate evaluation of medical processes and
outcomes
ICD-10 Changes
ICD-10-CM Codes Compared to ICD-9-CM Codes
No Mapping,
3.0%
ICD-9
465.9
Complex
Mapping,
2.8%
1 to Many,
2.1%
Match with
Multiple
Choices,
18.7%
ICD-10
J06.9
Acute upper
respiratory infection,
unspecified
Exact Match,
24.2%
Approximate
Match, 49.1%
ICD-9
034.0
Streptococcal sore
throat
ICD-10
J03.00
Acute streptococcal
tonsillitis,
unspecified
CODING
CONVENTIONS
AND
GUIDELINES
ICD-10-CM Codes
Where do I find the codes?
2015 Coding Manual
2016 ICD-10-CM is available at:
http://www.cdc.gov/nchs/icd/icd10cm.htm
or
https://www.cms.gov/Medicare/Coding/ICD10/index.html
ICD-10-CM Official Guidelines for
Coding and Reporting
FY 2016
Narrative changes appear in bold text
Items underlined have been moved within the guidelines since the FY 2014
version Italics are used to indicate revisions to heading changes
ICD-10-CM – Chapter Overview
First Character(s)
Chapter
A and B
C and D(49)
D
E
1
2
3
4
F
G
H (H1-H59)
H (60-95)
I
J
K
L
M
N
O
P
Q
R
S-T
V-Y
Z
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
Title
ICD-10-CM – Chapter Overview
First Character(s)
First
Character(s)
Chapter
Title
Chapter
and BB
AA and
and D(49)
D(49)
CC and
D
D
EE
1
2
3
4
Infectious
and Parasitic
Diseases
Antibodies/Bacteria/Bugs
1
Infectious
and Parasitic Diseases
Neoplasms
Cancer
2
Neoplasms
Diseases
of Blood/ Immune
Dracula
3
DiseasesMechanism
of Blood/ Immune Mechanism
Endocrine,
Nutritional
and Metabolic
Diseases
Endocrine
4
Endocrine,
Nutritional
and Metabolic
Diseases
FF
5
G
G
H
H (H1-H59)
(H1-H59)
H
H (60-95)
(60-95)
II
JJ
KK
LL
M
M
6
7
8
9
10
11
12
13
N
N
O
O
14
15
Mental,
Behavior and
neurodevelopmental
Flaky, frightened,
fitful, fearful
5
Mental,
Behavior and neurodevelopmental
disorders
disorders
6
Diseases
of NervousDiseases
System of Nervous System Ganglia, gray matter
7
Diseases
of Eye andDiseases
Adnexa of Eye and Adnexa Headlight
8
Diseases
of the
Ear and Mastoid
Process
Diseases
of the Ear and
Mastoid
Process
Hearing
Diseases
of Circulatory
System
9
Diseases
of Circulatory SystemIn motion,
Disease
of the Respiratory
JR (from Dallas) J=Respiratory
10
DiseaseSystem
of the Respiratory System
Diseases
of
Digestive
System
11
Diseases of Digestive System Kaopectate “Krohn’s”, “Kolitis”
Diseases
of Skin andDiseases
Subcutaneous
Lesions,
Lotion
12
of Skin Tissue
and Subcutaneous
Tissue
Diseases
of Musculoskeletal
and
Muscles
13
Diseases System
of Musculoskeletal
System
and Connective Tissue
Connective Tissue
14
Diseases
of Genitourinary System
Diseases
of Genitourinary
System
Need to pee
15
Pregnancy,
Childbirth and the Puerperium
Pregnancy,
Childbirth
and the Puerperium
OB
PP
Q
Q
16
17
RR
18
S-T
S-T
19
V-Y
ZV-Y
Z
20
21
Title
Cheat Name
16
Conditions
Originating
Period
Conditions
Originating
in Perinatal
Period in Perinatal
Perinatal
17
Congenital
Malformations,
and Chromosomal Abnormalities
Congenital
Malformations,
Deformations,
and Deformations,
Quirky, quandary
Chromosomal Abnormalities
18
Symptoms,
andand
Abnormal
Clinical andReview
Laboratory
Findings
Symptoms,
Signs and
AbnormalSigns
Clinical
Revelations.
and Ratios
Laboratory Findings
19
Injury, Poisoning and Certain Consequences of External Causes
Injury, Poisoning and Certain Consequences of
Situations, Traumas
External
Causes
20
External Causes of Morbidity
External
Causes
of
Morbidity
Vehicles,
walking,
eXposure,
21
Factors Influencing Health Status
and Contact
with
Health Services
Factors Influencing Health Status and Contact
Zombie
with Health Services
ICD-10 Hierarchy
H65 Nonsuppurative otitis media
H65.0 Acute serous otitis media
H65.00 …… unspecified ear
H65.01 …… right ear
H65.02 …… left ear
H65.03 …… bilateral
H65.04 …… recurrent, right ear
H65.05 …… recurrent, left ear
H65.06 …… recurrent, bilateral
H65.07 …… recurrent, unspecified ear
ICD-10 Hierarchy
S60 Superficial injury of wrist, hand and fingers
S60.0 Contusion of finger without damage to nail
S60.00 Contusion of unspecified finger without damage to nail
S60.00XA …… initial encounter
S60.00XD …… subsequent encounter
S60.00XS …… sequela
S60.01 Contusion of thumb without damage to nail
S60.011 Contusion of right thumb without damage to nail
S60.011A …… initial encounter
S60.011D …… subsequent encounter
S60.011S …… sequela
S60.012 Contusion of left thumb without damage to nail
S60.012A …… initial encounter
S60.012D …… subsequent encounter
S60.012S …… sequela
S60.019 Contusion of unspecified thumb without damage to nail
S60.019A …… initial encounter
S60.019D …… subsequent encounter
S60.019S …… sequela
S60.02 Contusion of index finger without damage to nail
S60.021 Contusion of right index finger without damage to nail
ICD-10-CM Structure
This example of an ICD-10-CM code is for the ‘injury of digital
nerve of right index finger, initial encounter’.
This one code shows laterality, anatomic site, encounter type,
and the specific underlying disease.
Differences from ICD-9-CM
• Expanded detail and specificity
• Laterality (side of the body
affected) has been added to
relevant codes
•Expanded use of combination codes
• Poisonings and associated external cause
• Certain conditions and associated common symptoms or
manifestations
• Injuries grouped by anatomical site rather than type of injury
• Excludes 2 note which means “NOT INCLUDED HERE”.
Addition of 7th
Character
• 7th character used in
certain chapters (e.g.,
Obstetrics, Injury,
Musculoskeletal, and
External Cause chapters)
• Different meaning
depending on section
where it is being used
• Must always be used in the
7th character position
• When 7th character applies,
codes missing 7th character
are invalid
Placeholder “X”
• Addition of dummy placeholder “X”
(or “x”) is used in certain codes to:
• Allow for future expansion
• Fill out empty characters when
a code contains fewer than 6
characters and a 7th character
applies
S50.01XA Contusion of R elbow
Unspecified Codes
• Unspecified codes should need to be selected
less often due to greater number of code choices
in ICD-10-CM
• Each healthcare encounter should be coded to the level of certainty
known for that encounter
• Unspecified codes should be reported when they most accurately
reflect what is known about the patient’s condition at the time of that
particular encounter
Routine Well-Child Exams
Routine Checks
Z00.121
Encounter for routine child health examination with
abnormal findings
Use additional code to identify abnormal findings
Z00.129
Encounter for routine child health examination without
abnormal findings
Immunizations
ICD-9 CM
V04.81 Need for prophylactic vaccination and inoculation,
influenza
Unlike ICD-9, ICD-10
does not have separate
codes for types of
immunization
ICD-10 CM
Z23 Encounter for immunization
Code first any routine childhood examination
Upper Respiratory Infections
ICD-9 CM
465.9 Acute upper respiratory infections of unspecified site
ICD-10 CM
J06.9 Acute upper respiratory infection, unspecified
Excludes 1 Note = “Not coded here!” Use 1 code only
Acute respiratory infections NOS (J22)
Influenza virus (J09-J11)
Streptococcal pharygitis (J02.0)
Acute Pharyngitis
ICD-9 CM
462 Acute pharyngitis
ICD-10 CM
J02.9 Acute pharyngitis, unspecified
Sore throat NOS
Pharyngitis (acute) NOS
Etc.
OR
ICD-10 CM
J02.8 Acute pharyngitis due to other specified organisms
Use additional code B95-B97 to identify infectious agent
Tobacco Exposure
Is required to be coded with many conditions,
including but not limited to:
Otitis Media
Respiratory conditions
Cardiovascular conditions
Z77.22 Exposure to environmental tobacco smoke
Z72.0 Tobacco use
Documentation Drives the Process
Documentation
- Continuity of Care
- Basis for code
assignment
Reimbursement
Coding
- Paid or delayed?
- Based on documentation
- Directly affects cash flow
Here are some
of the major
effects of the
changes within
ICD-10-CM that
impacts provider
documentation
and the coding of
the medical
record.
•
•
•
•
•
•
•
•
•
Axis of Classification
Possible 7-character codes
Laterality
Trimester Specificity
Drug and Alcohol Code Expansion
7th Character Expansion Codes
Complication Codes
Combination Codes
Increased Specificity
Clinical Documentation Tips
21 Clinical Concepts
•
•
•
•
•
•
•
•
•
•
•
Type
Temporal Factors
Severity
Caused By/Contributing Factors
Symptoms/Manifestations
Associated with
Complicated by
Localization/Laterality
Anatomy
Remission Status
History of
•
•
•
•
•
•
•
•
•
•
External Cause
Activity
Place of Occurrence
Episode
Number of Gestations
Outcome of Delivery
BMI
Morphology
Loss of Consciousness
Substance
●
Tobacco use or exposure, or
nicotine dependence (additional
code required)
INJURIES
ICD-9 used separate “E codes” to record external causes of injury. ICD-10 better
incorporates these codes and expands sections on poisonings and toxins.
When documenting injuries, include the following:
1. Episode of Care
e.g. Initial, subsequent, sequelae
2. Injury Site
Be as specific as possible
3. Etiology
How was the injury sustained (e.g. sports,
pedestrian, slip and fall, environmental
exposure, etc.)?
4. Place of Occurrence
e.g. School, work, etc.
Initial encounters may also require, where appropriate:
1. Intent
e.g. Unintentional or accidental, self-harm,
etc.
Strep Throat
Scenario 1: A 14 year-old boy presents with a sore
throat, fever, difficulty swallowing. He has a fever
of 102.8, otherwise his vitals are normal. His
tonsils are enlarged and red. This is his second visit
for the same symptoms.
His rapid stress test is positive and a 10 day course
of antibiotics is prescribed.
Strep Throat
Summary of ICD-10-CM Impacts
1. If confirmed as strep throat, must be documented as
streptococcal pharyngitis and/or streptococcal tonsillitis, not
sore throat.
2. Must specify if recurrent or not. If it is recurrent, specify date or
timeframe of recurrence. If not specified as recurrent, the
default is unspecified.
3. All respiratory conditions should include documentation
related to tobacco smoke exposure, history of tobacco use,
tobacco use, or tobacco dependence
Strep Throat
What if we use these codes?
ICD-9-CM Diagnosis Codes
034.0
NA
Streptococcal sore throat
ICD-10-CM Diagnosis Codes
Acute recurrent streptococcal
J03.01
tonsillitis
Z77.22
Contact with and exposure to
environmental tobacco smoke
How does the documentation need to be
improved?
Strep Throat
Chief Complaint
• Sore throat
HPI
• 14 year old boy presents with sore throat, fever, difficulty swallowing. This is his
second visit for the same symptoms
• _______________________________________________________________
In the last 2 months, diagnosed as strep before
• ________________________________________________________________
His father is a smoker.
Medications
• None, except for Tylenol to reduce fever
Exam
• Vitals: T 102.8°F, otherwise normal.
• Tonsils are enlarged and red
Assessment and Plan
for streptococcal tonsillitis
Rapid strep test is positive ____________________________________________
• 10 day course of antibiotics is prescribed
Otitis Media
Scenario 2: A 16 year-old patient complaining of ear
pain, from which he awoke during the night. He states
this is the third time this year he has had earaches. He
received amoxicillin for previous episodes which resolved
w/o problems. His TMs are deep red, dull, full and
landmarks obscured.
He is diagnosed with Otitis Media and given a
prescription of Augmentin x 10 days, f/u appt. in 2 weeks.
Otitis Media
Summary of ICD-10-CM (and other coding)
Impacts-Otitis Media
1. Document laterality
2. Coding note: Use additional code to identify
exposure to environmental tobacco smoke
3. Document type
4. Document contributing factors
5. Document temporal aspect of disease
What if we use these codes?
ICD-9-CM Diagnosis Codes
Chronic serous otitis
381.10 media, simple or
unspecified
NA
ICD-10-CM Diagnosis Codes
H65.23
Chronic serous otitis media,
bilateral
Z77.22
Contact with and exposure to
environmental tobacco smoke
How does the documentation need to be
improved?
Chief Complaint
• Ear Pain
HPI
• 13 year-old patient complaining of ear pain, from which he awoke during the night. His
mom states this is the third time this year he has had earaches. He received amoxicillin for
previous episodes which resolved w/o problems
• No upper respiratory symptoms, no recent head trauma, no history of allergies
Mother and father are non-smokers, however his
• _______________________________________________________________
grandfather, whom he stays with after school, is.
________________________________________________(exposure
to tobacco smoke)
Medications
• None
Exam
• Vitals: HT: 69” WT: 109, BP 110/60, T 99.2°F, HR 70, R 16
bilaterally
• TMs deep red, dull, landmarks obscured, full ______________
(laterality)
• Post auricular and submandibular nodes on left are palpable and slightly tender
Assessment and Plan
bilateral
Serous
• Chronic
____________ (temporal) _____________
(type) Otitis Media , ___________
(laterality)
• Prescription for Augmentin x 10 days, follow-up appointment in 2 weeks
Scenario 3: A 17-year-old established patient seen for
“check-up” and initiation of contraception; Menses are
regular; no complaints; She reports that her mother had
breast cancer. Sexual debut 6 months ago; 2 lifetime
partners; she admits to smoking about ½ pack of
cigarettes daily. Vitals checked.
Vaginal swab for SDTs; Given prescription for Ortho-Evra
patch.
What if we use these codes?
ICD-9-CM Diagnosis Codes
Z30.018
ICD-10-CM Diagnosis Codes
Encounter for initial prescription of other
contraceptives
V25.02
General counseling on initiation
of other contraceptive measures
V74.5
Screening examination for
venereal disease
Z11.3
Encounter for screening for infections
with a predominantly sexual mode of
transmission
V37.88
(V37.98)
Special screening examination for
other specified (or unspecified)
chlamydial diseases
Z11.8
Encounter for screening for other
infectious and parasitic diseases
Z80.3
Family history of malignant neoplasm of
breast
Z72.0
Tobacco use
V16.3
V69.8
Family history of malignant
neoplasm of breast
Other problems related to
lifestyle
How does the documentation need to be
improved?
Summary of ICD-10-CM (and other coding)
Impacts- Family Planning
1. Document encounter type
• Be sure to include a billable encounter type that can be
coded
2. For screenings – document screening type
• Important for many quality initiatives
3. Document any high-risk sexual behavior
• ICD-10 requires type: homosexual, heterosexual or bisexual
Chief Complaint
• Wants contraceptives
HPI
• A 17-year-old established patient seen for “check-up” and initiation of contraception
• Menses are regular; no complaints
• She reports that her mother had breast cancer.
• Sexual debut 6 months ago; 2 lifetime partners Does more need to be
documented to determine risk?
• Medications
• None
Exam
• Vitals: HT: 66” WT: 156, BP 112/70, T 97.8°F, HR 70, R 16
Assessment and Plan
: Gonorrhea; Chlamydia
• Vaginal swab done for STDs ________________________________________
• Given prescription for Ortho-Evra patch
Post-Implementation Survey
What grade would you give your organization’s
ICD-10 implementation?
How many of you believe that coding/billing
productivity has suffered?
How many of you believe that your ICD-10
billing will negatively impact your revenue?
For how long?
One Clinic’s Experience
1. So much for the CMS grace period. CMS promised a year of accepting ICD-10 claims as long as the
code is in the "right family" but other insurers have not followed suit. There is no promise there that
commercial plans won't require specificity for paying us. For the most part, in order to ensure being
paid, we must code to the highest level of specificity right from the beginning. I heard many doctors
adding more than 1 hour a day just to enter correct ICD-10 codes.
2. Clearinghouses. My clearinghouse kicked out all unspecified codes and will not submit them to
any insurance carrier.
3. Referrals. As a primary care physician, I do many referrals. My largest payer requires on-line
referral submissions. Yet, on October 1, their site did not allow ICD-10 codes to be submitted. They
no longer allow paper referrals and I was unable to do any for 3 days. Patients sometimes need
urgent referrals.
4. Eligibility checks. Some insurance websites were unavailable for the first 2 days. We were not
able to check eligibility on some patients. We may or may not be paid for these visits and according
to our insurance contracts, we are not allowed to bill the patient. Any patients I saw on the first 2
days of October who we were unable to verify their insurance was treated for free and there's
nothing I can do about it.
5. Wait times. One of my billers spent three hours on-hold with an insurance company.
6. Personnel. While IT systems may have been prepared for ICD-10, the industry personnel not so
much. One of my billers was calling about a previously denied claim and was told she needed to
resubmit it in ICD-10 format. No, this visit was 3 months ago and it does not apply. Many reps could
not answer ICD-10 related questions.
Post Implementation-Why?
Revenue Impact - Immediate
Denied claims
Loss of productivity
Revenue Impact - Future
Denied claims
Quality and impact on Value-based Payment
Systems
Post Implementation-Who?
Providers
Billers
and
Coders
Admin
Post-Implementation Team
Administration
Provider
Billing/Coding
Quality Coordinators
Post Implementation-What?
Denial management strategy
Documentation audits
Continuing education
Quality and coding integration strategy
Denial Management Strategy
• Formal process to track denied claims, based on incorrect or
invalid code
Ins Co. Patient
ID#
Charge
Amount
CPT Date
Diagnosis/ Reason for Denial
of
ICD-10 Code
Service
Action
Taken
IF ICD
Date F/U
errorSent
corrected
code
Documentation Audits
Rule #1: Select charts randomly
Pull every 5th chart until reaching 10 charts
Rule #2: Use the same rules as the auditors
Requires understanding of both ICD-10-CM and
E/M coding and documentation requirements
Rule #3: Keep coding audits results professional and
educational
Rule #4: Work at correcting errors
Audit Worksheet
Provider Name:
Reviewer:
Documented
CPT
ICD-10
Date
Patient ID Diagnosis
Code(s) Code(s) CPT Notes
10/2/2015 Jody
Gastroesophageal 99212 K21.9 Based on
Smith
reflux (GERD)
History and
MDM-should
be 99213
Documentation
Notes
To meet higher
specificity for ICD10, the
documentation
needs to indicate
with or w/o
esophagitis
Queries
Date: ______________________ Client Name: __________________________________
Client Record Number: __________________
CDI Program Reviewer: __________________ Clinician Name: ____________________
A review of the health record found a need for documentation clarification. There are
clinical indicators in the client record of a missed and/or incomplete diagnosis. The
relevant information is provided below.
Clinical Indicator/Medical Evidence
Please add/or consider one of the diagnoses commonly associated with the clinical
indicators that can be captured by coding.
I disagree with the need for additional documentation.
Post-Implementation- When?
Determine Timeline
Develop priorities
Delegate responsibility and authority
0-3
3-12
1-5
• Form post-implementation team
• Create denial mgmt. strategy
• Assess productivity
• Documentation & coding audits
• Continuing training and education
• Review Quality Data
• Continue audits
Post-Implementation: 0-3 Months
Days to bill
Days to payment
Review coder productivity
Develop and implement denial
management strategy
Review education opportunities
Revenue Cycle
Impact
Post Implementation: 3-12 Months
Review training/education needs and develop
continuing education plan
Begin documentation and coding audits
Review/mitigate revenue cycle impacts
Identify quality reporting and data integrity challenges
Meaningful Use
Quality scoring
Population management
Implementation 1-5 Years
Review and gap analysis
Continuing training and education
Expand audits
Review impact on value-based payment reform
Helpful ICD-10 Web Resources
http://michigan.gov/mdch/0,1607,7-132-2945_42542_42543_42546_42552_42696-256928--,00.html
Helpful ICD-10 Web Resources
• CMS ICD-10 overview page: http://www.cms.gov/ICD10/
• AHIMA ICD-10 Information: http://www.ahima.org/ICD10/default.aspx
• AAPC ICD-10 Information: http://www.aapc.com/icd-10/index.aspx
• HIMSS Playbook: http://www.himss.org/asp/topics_icd10playbook.asp
Helpful ICD-10 Web Resources
Road to 10: The Small Physician
Practice's Route to ICD-10
http://www.roadto10.org/
Helpful ICD-10: Free or Inexpensive
Resources - Converters
Resource
Name
Organization Summary
2015 ICD10 Medical
ICD10Data
Coding
Website
ICD-10
Code
Translator
AAPC
MTBC
ICD9-10
MTBC
Listing of ICD-10
Diagnosis Codes,
Index, and conversion
between ICD-9 and
ICD-10 codes
Allows for
comparison between
ICD-9 and ICD-10
codes.
Converts ICD-9 codes
to their respective
ICD-10 codes
Delivery Cost
Type
Resource location
Web
Free
http://www.icd10data.com/
Web
Free
Mobile
APP
Free
http://www.aapc.com/ICD10/codes/index.aspx
App store or Google Play
Helpful ICD-10: Free or Inexpensive
Resources- Training
Resource
Name
Organization
ICD-10
Interactive
World Health
Self
Organization
Learning
Tool
Summary
Delivery Cost
Type
The WHO Electronic
ICD-10 training tool is
designed for selfWeb
learning and is built
on a modular
structure.
Free
Resource location
http://apps.who.int/classifications/a
pps/icd/ICD10Training/
Helpful ICD-10: Free or Inexpensive
Resources- Crosswalks
AAPC- top 50 codes in 23
specialties mapped from
ICD-9 to ICD-10 in a
laminated document
$20.00 for AAPC members
$25.00 for non-members
https://www.aapc.com/icd10/crosswalks/
Helpful ICD-10: Free or Inexpensive
Resources- Clinical Documentation
Resource Name
Organization
ICD-10
Documentation AHIMA
Tips
ICD-10 Doc
Guide
Precyse
University
Summary
A large library of
documentation tips
for a given
diagnosis, condition
or disease
Documentation tips
and strategies to
document the
medical record with
the specificity
required for ICD-10
Delivery
Type
Cost
Resource location
Web
Free
http://bok.ahima.org/PdfView?
oid=300621
Mobile
App
Free
Apple App Store or Google Pay
Cindy Buege
AHIMA Ambassador , AHIMA
Approved ICD-10 Trainer
cbuege@mphi.org